Midwife Licensure Exam Health Assessment — Systematic Head-to-Toe & Body-System AssessmentRevision Notes

Exam Tips

• NLE frequently asks: 'What is the correct sequence for abdominal assessment?' — Answer: Inspect → Auscultate → Percuss → Palpate (IAPP).
• If asked about the overall body assessment sequence: head-to-toe, cephalocaudal direction.
• Vital signs are always part of the general survey — expect scenario-based questions testing whether you prioritize VS abnormalities correctly.
• Equipment-preparation questions: know which tool assesses which system (e.g., reflex hammer for DTRs, penlight for pupils).

Key Points

• Proceed in cephalocaudal (head-to-toe) direction — always compare bilateral findings for symmetry.
• Group assessment techniques to minimize unnecessary client repositioning and conserve energy.
• General survey comes first: observe overall appearance, level of consciousness (LOC), body habitus, hygiene, gait, and distress level before touching the client.
• Vital signs are part of the general survey: temperature (36.5–37.5°C oral), pulse (60–100/min), respirations (12–20/min), blood pressure (< 120/80 mmHg normal), and SpO2 (≥ 95%).
• Prepare equipment before entering: stethoscope, sphygmomanometer, penlight, thermometer, tape measure, reflex hammer, gloves, tongue blade.
• Maintain privacy (expose only area being examined), warmth (warm hands and stethoscope), and standard precautions throughout.
• Ask client to void before abdominal examination — a full bladder alters palpation findings.
• Position varies by region: sitting for head/neck/posterior thorax; supine for anterior chest/abdomen; standing for gait/balance assessment.
• Inform the client of each step before performing it — this is both an ethical duty (informed consent) and a legal standard under RA 9173.

Definitions

Section Title

Principles, Preparation, and General Survey

Common Mistakes

• Forgetting to ask the client to void before abdominal assessment — a full bladder mimics a palpable abdominal mass.
• Skipping bilateral comparison — many abnormalities (e.g., unequal pupils, unequal breath sounds) are only evident when sides are compared.
• Applying palpation or percussion before auscultation during abdominal assessment — this alters bowel sounds and gives inaccurate findings.
• Failing to explain each step to the client — violates RA 9173 standards of patient-centered care and may invalidate informed consent.
• Omitting standard precautions or skipping gloves for genitourinary/oral examination.

Exam Tips

• Memorize: capillary refill < 2–3 seconds = normal; ≥ 3 seconds = impaired perfusion.
• Clubbing nail-bed angle: 160° = normal; 180° or more = abnormal (chronic hypoxia).
• Pitting edema scale: 1+ to 4+. NLE may ask to grade based on depth description.
• Central cyanosis at the lips/tongue = immediately assess airway, breathing, circulation and call for help.
• Skin turgor test site: sternum or forearm — NOT the back of the hand in elderly clients.

Key Points

• Inspect for color, lesions, moisture, texture, and distribution; palpate for temperature, turgor, and edema.
• Normal skin: warm, dry, intact, color consistent with ethnicity, no lesions.
• Turgor: pinch skin over the forearm or sternum — normal recoil is IMMEDIATE (less than 2–3 seconds). Poor turgor (skin tenting) = dehydration.
• Capillary refill: press nail bed to blanch → release → color should return in less than 2–3 seconds. Delayed refill = poor peripheral perfusion.
• Hair: normally evenly distributed; alopecia can indicate hypothyroidism, malnutrition, or chemotherapy effects.
• Nails: normal nail-bed angle approximately 160° (Lovibond angle). Clubbing = angle 180° or greater, caused by chronic hypoxia (e.g., COPD, congenital heart disease).
• Cyanosis types: CENTRAL cyanosis (lips, tongue, mucous membranes) = low arterial oxygen saturation — systemic hypoxemia; PERIPHERAL cyanosis (fingertips, nail beds) = reduced circulation to extremities — less urgent than central.
• Jaundice (icteric skin/sclera) = elevated bilirubin; assess in natural light. In dark-skinned clients, assess sclera, oral mucosa, and palms.
• Pitting edema graded 1+ to 4+: 1+ = 2 mm depth, rapid rebound; 2+ = 4 mm; 3+ = 6 mm; 4+ = 8 mm, prolonged rebound.
• Unilateral edema suggests local cause (DVT, lymphedema); bilateral edema suggests systemic cause (heart failure, hypoalbuminemia, kidney disease).
• Pallor in dark-skinned clients: check conjunctiva, nail beds, and palms — not just the facial skin.

Definitions

Section Title

Integumentary System — Skin, Hair, and Nails

Common Mistakes

• Grading turgor over the back of the hand in elderly clients — use the sternum or forearm instead, as hand skin loses elasticity with age and gives false-positive tenting.
• Confusing central cyanosis (emergency) with peripheral cyanosis (less urgent) — lip/tongue involvement always means central and systemic.
• Forgetting that in dark-skinned clients, pallor is assessed at the conjunctiva, oral mucosa, and palms — not just the face.
• Misgrading pitting edema — remember the depth-in-millimeters correlation: 1+=2 mm, 2+=4 mm, 3+=6 mm, 4+=8 mm.

Exam Tips

• Trachea midline = normal. Deviation AWAY from affected side = tension pneumothorax (report immediately).
• Thyroid assessment: palpate from behind, ask client to swallow — must move up with swallowing.
• Hard, fixed, nontender lymph node = suspect malignancy → refer.
• Tender lymph node = infection/inflammation (acute process).
• Bell's palsy: entire face (including forehead) affected. CVA facial droop: forehead spared.

Key Points

• Inspect skull shape: normocephalic (round, symmetric) is normal. Microcephaly or macrocephaly are abnormal.
• Face: assess symmetry. CN VII (Facial nerve) controls facial expressions — ask client to smile, raise eyebrows, and puff cheeks.
• Facial droop = unilateral CN VII weakness. In Bell's palsy: entire half of face affected. In stroke: forehead spared (central lesion).
• Trachea: inspect and palpate for midline position. Tracheal deviation is an emergency finding — toward affected side in atelectasis/fibrosis; AWAY from affected side in tension pneumothorax or large pleural effusion.
• Thyroid gland: palpate from behind while client swallows. Normal = nonpalpable or small, smooth, firm, and moves upward with swallowing. Enlarged = goiter; nodular/hard/fixed = refer immediately.
• Lymph nodes (cervical, submandibular, occipital, axillary, inguinal): normal = nonpalpable or small (< 1 cm), soft, mobile, nontender.
• Abnormal lymph nodes: > 1 cm, hard, fixed, or tender. Tender = infection; hard + fixed + nontender = malignancy until proven otherwise.
• Head-to-toe mnemonic for cranial nerve assessment begins here — CN I (olfactory) assessed at nose, CN II onward in the eye examination.

Definitions

Section Title

Head, Face, and Neck

Common Mistakes

• Forgetting that normal lymph nodes can be nonpalpable — not finding them does NOT mean a problem.
• Confusing the direction of tracheal deviation: remember 'pushed away from the pressure' for tension pneumothorax.
• Not asking the client to swallow during thyroid palpation — the thyroid must move upward with swallowing to be properly assessed.
• Missing Bell's palsy vs. CVA distinction — forehead involvement is the key differentiator.

Exam Tips

• Fixed dilated pupil = brain herniation/neurologic emergency — IMMEDIATE action required.
• Pinpoint pupils + CNS depression = opioid toxicity → prepare naloxone.
• Otoscope: Adults pull UP and BACK; Children (< 3 years) pull DOWN and BACK.
• CN tested by eye exam: CN II (visual acuity), CN III/IV/VI (extraocular movement and pupil response), CN VII (eyelid closure).
• Uvula rises midline = CN IX and X intact. Deviates away from the side of the lesion.

Key Points

• PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation — the normal pupil finding. Pupils normally 3–5 mm in normal lighting.
• Assess pupillary light reflex: shine light in one eye — direct reflex (same eye constricts) and consensual reflex (other eye also constricts) should both be present.
• Accommodation: ask client to focus on a near object — pupils should constrict and eyes converge.
• Anisocoria = unequal pupils (may be normal variant in ~20% of population if < 1 mm difference and both reactive). Anisocoria with one fixed pupil = neurologic emergency.
• Fixed, DILATED pupil = neurologic emergency (CN III compression, herniation). Report STAT.
• Pinpoint pupils (miosis) = opioid toxicity or pontine hemorrhage.
• Sclera: normal white. Icteric (yellow) sclera = jaundice (elevated bilirubin). Injected (red) sclera = inflammation/infection.
• Conjunctiva: normal pink. Pale conjunctiva = anemia. Inflamed/red = conjunctivitis.
• Visual acuity tested with Snellen chart — normal 20/20. A result of 20/40 means the client sees at 20 feet what a normal person sees at 40 feet (worse than normal).
• Extraocular movements: 6 cardinal gazes test CN III, IV, and VI. Nystagmus (involuntary eye movement) is abnormal.
• Ear: pinna should align with the outer canthus of the eye. Low-set ears suggest chromosomal abnormalities (e.g., trisomy 21).
• Otoscopic exam: pull pinna UP and BACK (adult) or DOWN and BACK (child < 3 years) to straighten the ear canal.
• Tympanic membrane: normal = pearly gray, intact, with cone of light reflex visible. Bulging/red = otitis media. Perforated = hole in membrane.
• Whisper test: whisper 2-syllable words 30–60 cm from each ear (cover the other ear). Client should correctly repeat words — tests hearing.
• Nasal septum: should be midline. Deviated septum can obstruct airflow.
• Tonsil grading: 1+ = visible; 2+ = midway between pillars and uvula; 3+ = touching uvula; 4+ = touching each other ('kissing tonsils').
• Uvula rises MIDLINE on phonation ('say ahhh') — tests CN IX and X. Deviation = CN X palsy on the OPPOSITE side (uvula deviates AWAY from the lesion).
• Gag reflex tests CN IX (sensory) and CN X (motor) — should be present in adults.
• CN I (Olfactory): ask client to identify familiar scents with eyes closed, one nostril at a time.

Definitions

Section Title

Eyes, Ears, Nose, and Throat (HEENT)

Common Mistakes

• Pulling the pinna DOWN and BACK in an adult during otoscopy — this is the child technique (< 3 years). Adults: UP and BACK.
• Documenting anisocoria as abnormal without checking reactivity — if both pupils are reactive, small difference (< 1 mm) may be a normal variant.
• Confusing uvula deviation side — uvula deviates AWAY from the CN X lesion (it is pulled by the intact side).
• Forgetting that pinpoint pupils suggest opioid toxicity — always consider medication history.
• Interpreting 20/40 vision as better than 20/20 — the higher the bottom number, the WORSE the vision.

Exam Tips

• Memorize breath sound types and locations: Vesicular (peripheral), Bronchovesicular (main bronchi), Bronchial (trachea only).
• Adventitious sounds: Crackles = fluid; Wheezes = narrowed airways; Rhonchi = secretions (clears with cough); Pleural rub = inflamed pleura; Stridor = upper-airway obstruction (EMERGENCY).
• Barrel chest (1:1 AP ratio) = COPD/chronic emphysema.
• Percussion: Resonance = normal; Dullness = fluid or consolidation; Hyperresonance = trapped air (pneumothorax).
• SpO2 < 90% = severe hypoxemia → immediate nursing action and physician notification.

Key Points

• Normal respiratory rate: 12–20 breaths/min (adults). Less than 12 = bradypnea; more than 20 = tachypnea.
• Normal chest configuration: anteroposterior (AP) to transverse ratio approximately 1:2.
• Barrel chest: AP:transverse ratio approximately 1:1 — indicates chronic air trapping (COPD, emphysema).
• Assess for symmetric chest expansion: place hands on posterior chest at the 10th rib, thumbs touching at the midline — thumbs should move equally apart with inspiration.
• Percussion notes: RESONANCE over normal lung tissue; HYPERRESONANCE over trapped air (pneumothorax, emphysema); DULLNESS over consolidation (pneumonia, lobar collapse) or fluid (pleural effusion).
• Normal breath sounds by location: VESICULAR (soft, breezy, inspiration > expiration) over most peripheral lung fields; BRONCHOVESICULAR (moderate intensity, inspiration = expiration) over main bronchi (1st–2nd ICS anteriorly, scapular areas posteriorly); BRONCHIAL (loud, hollow, expiration > inspiration) over the trachea only.
• Bronchial sounds heard OVER peripheral lung tissue = ABNORMAL (consolidation, as in pneumonia).
• Adventitious (abnormal) breath sounds memorization: CRACKLES (rales) = discontinuous, popping/crackling sounds — fluid in alveoli (pneumonia, pulmonary edema/heart failure); WHEEZES = continuous, high-pitched musical sounds — narrowed airways (asthma, COPD, anaphylaxis); RHONCHI = low-pitched, snoring/gurgling — secretions in large airways (clears or changes with coughing); PLEURAL FRICTION RUB = grating, leathery sound — inflamed pleural surfaces (pleuritis); STRIDOR = high-pitched, crowing sound heard on INSPIRATION — upper-airway obstruction (croup, epiglottitis, foreign body, anaphylaxis) — EMERGENCY.
• Absent breath sounds = complete obstruction or large pleural effusion — EMERGENCY if unilateral and sudden.
• Dyspnea assessment: observe for nasal flaring, intercostal/subcostal retractions, use of accessory muscles (sternocleidomastoid, scalenes) — all signs of respiratory distress.
• Oxygen saturation (SpO2): normal ≥ 95%. SpO2 < 90% = severe hypoxemia → immediate intervention.

Definitions

Section Title

Respiratory System — Thorax and Lungs

Common Mistakes

• Calling bronchial sounds heard over the peripheral lung normal — bronchial sounds are ONLY normal over the trachea; over lung fields they indicate consolidation.
• Confusing wheezes with crackles — wheezes are continuous musical sounds (airway narrowing); crackles are discontinuous pops (fluid in alveoli).
• Forgetting that rhonchi may CLEAR with coughing — if adventitious sounds clear after coughing, they were likely secretions (rhonchi).
• Not auscultating ALL lung fields (anterior, lateral, and posterior) — missing posterior bases where fluid settles in an upright client.
• Overlooking stridor as 'just a noisy breath' — stridor is always an emergency finding.

Exam Tips

• APE To Man: memorize the order and locations of all five auscultation sites.
• S1 = apex (AV valves close); S2 = base (semilunar valves close).
• S3 in adult > 40 = heart failure → priority nursing diagnosis: Decreased Cardiac Output or Excess Fluid Volume.
• Pulse grading: 2+ = normal. 0 = absent → medical emergency (no perfusion to that limb).
• Pitting edema bilateral = systemic (HF, renal disease); unilateral = local (DVT, lymphedema).

Key Points

• Apical pulse location (PMI — Point of Maximum Impulse): 5th intercostal space (ICS), LEFT midclavicular line (LMCL). A displaced PMI (shifted laterally) suggests cardiomegaly.
• Count apical pulse for a FULL 60 seconds. Normal: 60–100/min, regular rhythm.
• Heart sounds: S1 ('lub') = closure of AV valves (Mitral + Tricuspid) at the START of systole — loudest at the APEX. S2 ('dub') = closure of semilunar valves (Aortic + Pulmonic) at the START of diastole — loudest at the BASE.
• Auscultation sites and mnemonic APE To Man: Aortic (2nd right ICS), Pulmonic (2nd left ICS), Erb's point (3rd left ICS — best site for S3/S4 and murmurs), Tricuspid (4th left ICS), Mitral/Apex (5th ICS at LMCL).
• S3 gallop ('lub-dub-dub'): early diastole, low-pitched. In adults > 40 years = ABNORMAL (suggests heart failure/fluid overload — ventricular overfilling). Normal in children and young adults.
• S4 gallop ('dee-lub-dub'): late diastole, low-pitched. Always ABNORMAL — indicates a stiff, non-compliant ventricle (hypertension, hypertrophic cardiomyopathy).
• Murmurs = turbulent blood flow; described by timing (systolic vs. diastolic), location, radiation, intensity (Levine scale 1–6), quality, and pitch.
• Peripheral pulses graded 0–3+: 0 = absent; 1+ = weak/thready; 2+ = normal/brisk; 3+ = bounding. Assess bilaterally for symmetry.
• Arterial insufficiency findings: diminished/absent pulses, cool/pale/shiny skin, hairless extremity, intermittent claudication, dependent rubor, elevation pallor, and ulcers on toes/heels.
• Venous insufficiency findings: brawny (brownish) discoloration around ankles, edema, varicosities, and stasis ulcers on medial malleolus — pulses typically present.
• Pitting edema: grade 1+ (2 mm), 2+ (4 mm), 3+ (6 mm), 4+ (8 mm). Bilateral = systemic cause; unilateral = local cause (DVT).
• DVT signs: unilateral calf pain, swelling, warmth, and redness — Homan's sign (calf pain on dorsiflexion) is NOT reliable enough to confirm DVT but may be tested in NLE context.
• Jugular venous distension (JVD): measured with the client at 30–45° — normal JVP ≤ 3 cm above sternal angle. Elevated JVP = right-sided heart failure or cardiac tamponade.

Definitions

Section Title

Cardiovascular System — Heart and Peripheral Vascular

Common Mistakes

• Placing PMI at the 4th ICS or right side — PMI is always at the 5th ICS, LEFT MCL in a normal heart.
• Confusing S1 and S2 valve associations: S1 = AV valves (Mitral + Tricuspid); S2 = Semilunar valves (Aortic + Pulmonic).
• Stating S3 is always abnormal — S3 is NORMAL in children and young adults but abnormal in adults > 40.
• Not comparing pulses bilaterally — an asymmetric pulse suggests arterial disease on the weaker side.
• Confusing arterial and venous insufficiency findings — arterial = pale, cool, absent pulses; venous = edema, brownish discoloration, pulses present.

Formulas

Exam Tips

• Abdominal sequence: IAPP — Inspect, Auscultate, Percuss, Palpate. This is the single most tested sequence change in Health Assessment.
• Bowel sounds: normal 5–30/min. Absent = listen 5 full minutes first. Hypoactive = ileus/peritonitis (emergency). Hyperactive = early obstruction/diarrhea.
• Pulsatile mass = stop palpating + notify physician (possible aortic aneurysm).
• Rebound tenderness = peritoneal irritation = surgical emergency.
• Liver span: 6–12 cm at right MCL. Larger = hepatomegaly; smaller = cirrhosis (liver shrinkage in late stage).
• Urine output < 0.5 mL/kg/hr = oliguria → assess for renal failure, shock, or fluid deficit.

Key Points

• CRITICAL sequence change: Inspect → Auscultate → Percuss → Palpate (IAPP). Auscultation comes BEFORE percussion and palpation to avoid altering bowel sounds.
• Inspect: abdomen shape (flat, rounded, scaphoid, distended), symmetry, visible peristalsis, pulsations, skin characteristics, umbilicus (midline and inverted normal), and any visible masses.
• Auscultate: listen for bowel sounds in ALL four quadrants. Normal = 5–30 gurgles per minute. Hypoactive/absent = listen a FULL 5 minutes before charting absent (ileus, peritonitis). Hyperactive (borborygmi) = early obstruction, diarrhea, gastroenteritis.
• Also auscultate for bruits over the aorta, renal arteries, iliac arteries, and femoral arteries — a bruit indicates vascular narrowing (stenosis).
• Percuss: tympany (gas) dominant over most of the abdomen — normal. Dullness over solid organs (liver, spleen) or fluid-filled areas.
• Liver span at right MCL: percuss from resonance (lung) downward to dullness (liver upper border), then from tympany (bowel below) upward to dullness (liver lower border). Normal span = 6–12 cm.
• Palpate: light palpation first (tenderness, guarding, masses), then deep palpation. Start AWAY from the area of pain.
• Normal: abdomen soft, nontender, no palpable masses. The liver and spleen are normally NOT palpable (if palpable, they are enlarged).
• Spleen: percuss at Traube's space (left lower thorax) — resonance is normal. Dullness = splenomegaly.
• Rebound tenderness (Blumberg's sign): press firmly and RELEASE suddenly — pain on release = peritoneal irritation (peritonitis, appendicitis). Report IMMEDIATELY.
• Rovsing's sign: pressure on LEFT lower quadrant causes pain in RIGHT lower quadrant = appendicitis.
• NEVER palpate deeply or firmly over a PULSATILE ABDOMINAL MASS — this may represent an aortic aneurysm. Notify physician immediately.
• Fluid wave and shifting dullness tests: assess for ascites (fluid accumulation in peritoneal cavity).
• McBurney's point: 1/3 of the way from the right anterior superior iliac spine (ASIS) to the umbilicus — rebound tenderness here indicates appendicitis.
• Normal adult urine output: 0.5–1 mL/kg/hr (approximately 1500 mL/day for a 70-kg adult). Oliguria < 400 mL/day; anuria < 100 mL/day.

Definitions

Section Title

Abdominal Assessment

Common Mistakes

• Palpating or percussing the abdomen BEFORE auscultating — alters bowel sounds and invalidates the assessment.
• Declaring bowel sounds 'absent' after only 1–2 minutes of listening — must listen for a FULL 5 minutes in each quadrant before documenting absent bowel sounds.
• Palpating a pulsatile abdominal mass deeply — this is dangerous and contraindicated.
• Starting palpation at the area of greatest pain — always start AWAY from pain to prevent guarding and elicit the most accurate assessment.
• Forgetting to warm the stethoscope before abdominal auscultation — cold contact causes muscle tensing that alters findings.

Formulas

Exam Tips

• GCS components: Eye (4) + Verbal (5) + Motor (6) = 15 maximum. Score ≤ 8 = coma → protect airway.
• Babinski: DOWN toes = normal adult. UP/fanning toes = abnormal adult = UMN lesion.
• DTR 2+ = normal. 4+ with clonus = hyperreflexia (UMN lesion). 0 = absent (LMN lesion or peripheral neuropathy).
• Nuchal rigidity + fever + severe headache = meningitis triad → report, isolate, prepare lumbar puncture setup.
• FAST: any sudden facial droop, arm weakness, or speech difficulty = STROKE → call code/physician immediately.
• Mnemonic for cranial nerves: 'On Old Olympus Towering Tops A Finn And German Viewed Some Hops' = Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Acoustic/Vestibulocochlear, Glossopharyngeal, Vagus, Spinal Accessory, Hypoglossal.

Key Points

• Level of consciousness (LOC) is assessed FIRST in the neurologic exam — it is the most sensitive indicator of neurologic change.
• LOC spectrum: Alert → Confused → Lethargic (drowsy but arousable) → Obtunded (difficult to arouse) → Stuporous (arousable only with vigorous stimulation) → Comatose (unarousable).
• Glasgow Coma Scale (GCS): THREE components — Eye Opening (E: 1–4), Verbal Response (V: 1–5), Motor Response (M: 1–6). Maximum score = 15 (fully alert); Minimum = 3 (deep coma).
• GCS ≤ 8 = coma → AIRWAY AT RISK → highest nursing priority is airway protection (intubation may be needed). Report IMMEDIATELY.
• GCS ≤ 8 triggers: position client to maintain airway (lateral recovery position if no spinal injury), prepare for possible intubation.
• Orientation: assess person (name), place (where they are), and time (date/year). Disorientation in that order usually = time lost first, then place, then person (most severe).
• Cranial nerve assessment (12 CNs): CN I Olfactory (smell), CN II Optic (visual acuity), CN III Oculomotor (pupil/eyelid/most EOM), CN IV Trochlear (downward-inward gaze), CN V Trigeminal (facial sensation + mastication), CN VI Abducens (lateral gaze), CN VII Facial (facial expression + taste), CN VIII Vestibulocochlear (hearing + balance), CN IX Glossopharyngeal (taste + gag sensory), CN X Vagus (gag motor + swallowing + voice + autonomics), CN XI Accessory (shoulder shrug + head turn), CN XII Hypoglossal (tongue movement).
• DTR (Deep Tendon Reflexes) grading: 0 = absent; 1+ = diminished; 2+ = normal; 3+ = brisk (may be normal or mild hyperreflexia); 4+ = hyperactive with clonus (abnormal). NLE answer: 2+ = normal.
• Plantar reflex (Babinski): stroke lateral sole of foot from heel to ball, then medially across the toes. NORMAL adult response: toes curl DOWN (plantar flexion). ABNORMAL (Babinski positive): big toe extends UP, other toes fan out (dorsiflexion + fanning) = upper motor neuron lesion (stroke, spinal cord injury, TBI). Normal in infants under 2 years.
• Romberg test: client stands with feet together and eyes open, then eyes closed — negative (normal) = maintains balance with eyes closed. Positive (abnormal) = sways or falls with eyes closed = proprioceptive or vestibular problem.
• FAST mnemonic for stroke: Face drooping, Arm weakness, Speech difficulty, Time to call for help. Recognize and report stroke signs immediately.
• Meningeal signs: Nuchal rigidity (stiff neck — pain/resistance on passive neck flexion), Kernig's sign (pain/resistance when extending knee with hip flexed), Brudzinski's sign (involuntary hip/knee flexion when neck is flexed) — all indicate meningeal irritation (meningitis).
• Mental status exam components: Appearance, Behavior, Cognition, Orientation, Memory (recent and remote), Mood and Affect, Thought content, Insight and Judgment.

Definitions

Section Title

Neurologic Assessment

Common Mistakes

• Forgetting that GCS ≤ 8 = coma and airway at risk — the FIRST priority is always AIRWAY, not further neurologic assessment.
• Thinking positive Babinski is normal in adults — it is only normal in infants under 2 years. In adults, it always indicates UMN pathology.
• Confusing Kernig's and Brudzinski's signs — Kernig: extend knee with hip flexed = pain/resistance. Brudzinski: flex neck = legs flex involuntarily.
• Assessing orientation only to 'person' and 'place' — always include 'time' (the earliest and most sensitive orientation deficit).
• Missing that a declining GCS score from one assessment to the next is an emergency — trend matters more than a single value.

Exam Tips

• Muscle strength 5/5 = full normal strength. 0/5 = no movement at all (paralysis).
• Crepitus + joint pain + bony enlargement at DIP joints = osteoarthritis (Heberden's nodes).
• Crepitus + joint pain + PIP joint enlargement + systemic symptoms = rheumatoid arthritis (Bouchard's nodes).
• Scoliosis screening: Adams forward bend test — observe for spinal curvature and rib humping.

Key Points

• Assess joints for ROM (Range of Motion), symmetry, swelling, tenderness, warmth, and crepitus.
• Assess muscle strength bilaterally using the 0–5 scale: 0 = no contraction; 1 = visible/palpable contraction but no movement; 2 = movement with gravity eliminated; 3 = movement against gravity only; 4 = movement against some resistance; 5 = FULL strength against full resistance (NORMAL).
• Assess gait: normal gait is smooth, symmetric, with appropriate heel-to-toe stride. Observe for limping, shuffling (Parkinson's), wide-based gait (cerebellar ataxia), or antalgic gait (pain-related).
• Crepitus: grating/crackling sensation or sound during joint movement — indicates rough joint surfaces (osteoarthritis, cartilage damage).
• Assess posture: kyphosis (exaggerated thoracic curve, 'hunchback'), lordosis (exaggerated lumbar curve), and scoliosis (lateral spinal curvature — screened by Adams forward bend test).
• Muscle atrophy (wasting) suggests disuse, denervation, or malnutrition.
• Joint deformities: Bouchard's nodes (proximal interphalangeal joints — rheumatoid arthritis), Heberden's nodes (distal interphalangeal joints — osteoarthritis), ulnar deviation (RA), and swan-neck or boutonnière deformities (RA).
• Assess for leg length discrepancy — measured from ASIS to medial malleolus.
• Trendelenburg test: standing on one leg — positive (gluteus medius weakness) if pelvis drops on the raised-leg side.

Definitions

Section Title

Musculoskeletal Assessment

Common Mistakes

• Grading muscle strength as '4' when the patient can move against gravity but not resistance — grade 3 is 'against gravity only'; grade 4 requires movement against SOME resistance.
• Assessing ROM only in one direction — always assess full range (flexion, extension, abduction, adduction, internal/external rotation) as appropriate per joint.
• Forgetting to compare bilaterally — unilateral weakness or atrophy is more clinically significant than bilateral.

Exam Tips

• Normal urine output: 0.5–1 mL/kg/hr. Less than 0.5 mL/kg/hr = oliguria → immediate action.
• Normal urine: clear, pale to amber, no odor, no protein/glucose/blood.
• Palpable bladder after voiding = urinary retention → consider bladder scan and catheterization order.
• BSE timing: 7–10 days after onset of menstruation. TSE: monthly after warm shower.
• Hard, painless, fixed breast lump + skin dimpling + bloody nipple discharge = refer for malignancy workup.

Key Points

• Bladder assessment: normal bladder is NOT palpable after voiding. A palpable bladder = urinary retention → catheterization may be needed.
• Normal adult urine output: 0.5–1 mL/kg/hr (approximately 1500 mL/day for an average adult). Oliguria = less than 400 mL/day; anuria = less than 100 mL/day.
• Normal urine characteristics: clear, pale yellow to amber, pH 4.5–8.0, specific gravity 1.010–1.030, no protein, glucose, blood, or RBCs on dipstick.
• Abnormal urine: cloudy + foul-smelling = infection (UTI). Hematuria (blood in urine) = UTI, stones, trauma, or malignancy. Dark orange-brown = concentrated or jaundice-related. Bright red = fresh bleeding (emergency).
• Male genitalia: inspect for circumcision status, urethral meatus position (hypospadias = inferior surface; epispadias = superior surface), scrotal symmetry. Left testicle normally hangs slightly lower than right. Any hard, painless testicular mass = refer for malignancy.
• Female genitalia: inspect external genitalia for lesions, discharge, inflammation. Internal assessment (speculum and bimanual exam) performed by advanced practice nurses or physicians — beyond standard BSN scope for NLE but results must be documented and reported.
• Pap smear (cervical cytology): recommended every 3 years for women aged 21–65 (or as per DOH Philippines guidelines).
• Breast self-examination (BSE): best performed 7–10 days after the onset of menstruation (when breasts are least tender/swollen).
• Abnormal breast findings requiring referral: hard, irregular, fixed, painless lump; skin dimpling or peau d'orange; nipple retraction; bloody or spontaneous discharge; axillary lymphadenopathy.
• Testicular self-examination (TSE): monthly, best after warm bath or shower (scrotum most relaxed).

Definitions

Section Title

Genitourinary and Reproductive Assessment

Common Mistakes

• Forgetting to ask the client to void before abdominal/genitourinary assessment — a full bladder distorts findings.
• Interpreting dark amber urine as always pathologic — concentrated urine from dehydration is also dark amber; assess intake and turgor together.
• Missing that a palpable bladder after voiding = urinary retention — the bladder should NOT be palpable once emptied.

Exam Tips

• ABC priority: Airway > Breathing > Circulation > Neurologic > Everything else.
• Stridor = upper-airway obstruction = highest priority respiratory emergency.
• Central cyanosis (lips/tongue) + SpO2 < 90% = IMMEDIATE intervention.
• Declining GCS score = report first before further assessment — document exact score with time.
• SBAR format for reporting: know all four components and how to apply them in NLE scenario questions.
• Beck's triad = cardiac tamponade: Hypotension + Muffled heart sounds + JVD.
• 6 P's of acute arterial occlusion — all indicate limb-threatening emergency: report and act IMMEDIATELY.

Key Points

• ALWAYS prioritize using the ABC (Airway, Breathing, Circulation) framework first, then neurologic changes, then all other findings.
• Airway emergencies: STRIDOR (upper-airway obstruction), absent breath sounds (complete obstruction or large pneumothorax), inability to speak or cough.
• Breathing emergencies: central cyanosis (lips/tongue), SpO2 < 90%, respiratory rate < 8 or > 30 per minute, severe retractions and accessory muscle use.
• Circulation emergencies: absent peripheral pulse with cold/mottled/pale limb (acute arterial occlusion — 6 P's: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia), SBP < 90 mmHg, uncontrolled bleeding.
• Neurologic emergencies: rapidly DECLINING GCS (most critical), fixed dilated pupil (herniation), new-onset facial droop/arm weakness/speech difficulty (STROKE — FAST), positive Babinski in an adult.
• Other red flags: rebound tenderness (peritonitis), pulsatile abdominal mass (aortic aneurysm), nuchal rigidity + fever (meningitis), board-like abdomen, JVD with hypotension and muffled heart sounds (cardiac tamponade — Beck's triad).
• After identifying a red-flag finding: ASSESS the client (confirm finding), CALL for help (notify physician via SBAR), INTERVENE as per scope and standing orders, DOCUMENT with time and response.
• SBAR communication: Situation (what is happening), Background (relevant history), Assessment (your clinical judgment), Recommendation (what you need from the physician).
• Under RA 9173, the registered nurse is legally and ethically accountable for timely assessment, accurate reporting, and initiating appropriate nursing interventions within the scope of practice.

Definitions

Section Title

Red-Flag Findings and ABC Prioritization

Common Mistakes

• Prioritizing pain assessment over airway in an emergency scenario — pain is never the first priority; always ABC.
• Reporting findings to the charge nurse only when physician notification is clearly warranted — the nurse has a direct reporting responsibility under RA 9173.
• Waiting for all vital signs before reporting a rapidly deteriorating LOC — declining LOC requires IMMEDIATE notification.
• Elevating a limb with suspected acute arterial occlusion — elevation worsens ischemia. Keep limb flat or in dependent position.
• Missing Beck's triad components individually without synthesizing them into a diagnosis of cardiac tamponade.